Black Pepper Essential Oil to Enhance Intravenous Catheter Insertion in Patients With Poor Vein Visibility: A Controlled Study

Abstract

Objectives:

To evaluate the effect of topically applied black pepper essential oil on easing intravenous catheter insertion (IVC) in patients with no palpable or visible veins compared to a control group (standard nursing practice).

Design:

Randomized, controlled study.

Subjects:

One hundred twenty hospitalized patients, who were referred to a hospital vascular team because of difficulty in accessing veins for IVC insertion.

Interventions:

Topical application of 20% essential oil of black pepper in aloe vera gel or standard nursing care (hot packs with or without vigorous tactile stimulation).

Outcome Measures:

Pre- and post-test vein visibility and/or palpability and number of attempts at IVC insertion.

Results:

A higher percentage of patients achieved optimal scoring (vein score=2) or improved scoring (vein score of 1 or 2) to black pepper intervention than standard nursing care. The black pepper group also reduced the number of patients whose veins were still not visible or palpable after the intervention to nearly half that of the control group (p<0.05). The number of IVC attempts following black pepper was also half that of the control group.

Conclusion:

Topical application of black pepper is a viable and effective way to enhance vein visibility and palpability prior to intravenous insertion in patients with limited vein accessibility; it also improves ease of IVC insertion.

Introduction

I ntravenous catheter (IVC) therapy can be difficult to establish in some hospitalized patients. Difficulty is most common in patients who are dehydrated, or have had previous surgical procedures resulting in lymphedema or scar tissue.¹ Multiple attempts at IVC insertion are painful and distressing to the patient and time-consuming for the nurse or other health professional.² In order to minimize the number of attempts, bedside RNs at the mid-Atlantic suburban community teaching hospital where this study took place have the support of the hospital vascular resource team (VRT). The VRT is comprised of six RNs (VRNs) who have developed a high level of expertise in infusion and IVC insertion. This study aimed to replicate a previous small, unpublished pilot study at another hospitala that used black pepper essential oil to improve vein palpability and visualization and thus improve IVC accessibility, reducing patient distress and saving RN time.

Black pepper (Piper nigrum) is native to southern India and Indonesia, and these two countries account for about 50% of the world production. The pungent principal in pepper is an alkaloid-analog compound called piperine.³ Black pepper has a long history of use as a spice dating back 4000 years and was listed in old Chinese and Sanskrit texts. Theophrastus and Hippocrates mentioned its medicinal uses. Attila the Hun demanded 3000 pounds of pepper in ransom for Rome.⁴ Pepper is thought to have been distilled for the first time in the 15th century.⁵ The warming and stimulating properties of pepper were mentioned by early European herbalists, such as Joseph Miller.⁶

The antimicrobial activity of black pepper against Staphylococcus aureus in vitro is well documented.^7

–11 Black pepper has been found to increase serum drug assays by enhancing absorption of phenytoin, propranolol, and theophylline when ingested in doses of 300 to 600 mg per day.¹² Inhaled black pepper was found to enhance postural stability in older adults.¹³ Regarding the warming properties of black pepper, Buckle¹⁴ cites a study carried out by Port in 1999 (unpublished). This was a small randomized, controlled pilot study on the use of lavender and black pepper topically on eight patients with osteoarthritis. The patients that received lavender and black pepper had a reduction in stiffness and pain, and they needed fewer analgesics. More recently, the anti-inflammatory and anti-arthritic effects of piperine were tested in a rat model.¹⁵

Aloe vera gel was chosen for our study because it is non-oily. It was not chosen for any pharmacological effects. While aloe vera gel has been found to be anti-inflammatory and analgesic, these effects have occurred over several weeks, not within minutes,^16

–19 therefore we thought any effects from aloe vera gel, if any occurred within 10 minutes, would be minimal.

Between 2004 and 2007, four small pilot studies on the use of essential oils to improve vein visibility and palpability prior to ICV insertion were carried out by RNs for RJ Buckle's clinical aromatherapy certification courses. The most successful of these studies was by Story (2005) who applied a 20% solution of black pepper in a topical application to improve venous access in 10 patients as cited by Buckle.²⁰ The article prompted the PI (a VRN) to contact Lisa Story through RJ Buckle to discuss replicating the study.

Materials & Methodology

Study design

The study used a pretest, posttest, quasi-experimental design.²¹ The experimental group received 20% black pepper essential oil in a base of aloe vera gel applied topically to the site via roller ball 10 minutes prior to venipuncture. If no effect was noted, standard nursing care was provided. The control group received standard care alone. Standard care includes the application of a hot pack and/or vigorous tactile stimulation. The measurements were vein visibility, vein palpability, and the number of attempts at insertion of an IVC catheter.

Materials

The black pepper essential oil was supplied by Integrative Aromatherapy (www.aroma-rn.com). The aloe vera gel was supplied by Jancas (www.jancasinternational.com). Material safety data sheet (MSDS) and liquid chromatography data for the black pepper and aloe vera gel used in the study are available from the suppliers. The roller balls were supplied by Nemat International (www.nematinternational.com). With the exception of possible localized skin sensitivity, there have been no reports that contraindicate topical use.²²

Participants

Participants for the study were 120 hospital-based patients who were assessed as having no vein visibility or palpability. They were selected by a team of six VRNs. Exclusion criteria were pregnancy, lactating mothers, and children. The study was conducted over 3 months.

Assignment and human subjects

Patients were assigned systematically to treatment and control groups. Each of the six VRNs carried out standard care on 10 patients who met the inclusion criteria for study participation. The next 10 patients (for each six VRNs) were assigned to the black pepper group. This means each VRN collected data on 20 patients (10 black pepper and 10 standard care only), yielding 120 patients in total (60 in the black pepper group and 60 in the standard care control group.) Written consent was obtained from all participants. The study was reviewed and approved by the Institutional Review Board at the study site.

Method

Essential oil of black pepper was diluted to 20% in aloe vera gel and put into 60 empty roller balls by the PI. Ten roller balls were then given to each of the six VRNs who kept them in a room at ambient temperature. The VRNs participating in the research study reviewed the research method and data collection protocol: application method, pretesting for skin reaction, application of the black pepper oil or standard care, and the scoring tool to document vein visibility and palpability. The VRNs also completed Citiprogram training (Human Subject Protection Training).

Each participant in the black pepper group was patch-tested for any skin reaction prior to the intervention. (Patch-testing would identify irritation response but would not identify true sensitivity.) Patch-testing meant applying a dime-sized amount of 20% black pepper dilution to a patient's forearm using a roller ball dispenser. Each participant had a separate applicator. The patch test site was reassessed after exactly 10 minutes. Time was measured with an alarm timer. If there was any reaction (redness or irritation), the patients' forearm was immediately cleansed with alcohol to remove the remaining oil and the patient was removed from the study. If no reaction occurred, the VRN continued with the study. After assessing a vein in the back of the hand or forearm, the VRN assessed the vein for visibility and palpability and, if there appeared to be none, then applied the black pepper mixture. If the back of the hand was chosen, 10 swipes were used moving in a proximal to distal direction. If the forearm was selected, 12 swipes using the roller ball applicator were applied. The maximum dose of the black pepper/aloe vera gel mixture was 3 mL.

Measurement

The Vein Visibility and Palpability Score, used by Story (2005), was transferred into a Data Collection/Documentation Card (Please see Table 1). This tool was used to record vein visibility and palpability before and after the intervention. The scale for vein assessment included: 0=no vein visible or palpable; 1=vein visible OR palpable; and 2=vein visible AND palpable. The Data Collection/Documentation Card also recorded the number of attempts to access veins prior to the VRN's referral by the bedside nurse, and the number of attempts post-intervention by the VRN. Demographic data, including age and sex, were also documented as was the use of hot pack applications or tactile stimulation for the control group.

Table 1.

Template of Data Collection/Documentation Card

Patient no.	Age	Male/female	No. of attempts pre-application	Vein code pre-application	Intervention	Vein code post-application	No. of attempts post-application

Vein code: 0=no vein visible or palpable; 1=vein visible OR palpable; 2=vein visible AND palpable. Intervention: 1=hot pack; 2=vigorous tactile stimulation; 3=black pepper.

Data collection procedure for black pepper group

1. VRN receives referral from the bedside nurse for ICV access.

2. VRN assesses patient for study inclusion.

3. VRN reviews consent and completes with patient for the study.

4. VRN observes IVC site and rates vein visibility and palpability using Data Collection/Documentation Card and also completes demographic data.

5. VRN applies patch test of black pepper with roller ball applicator and observes 10 minutes following for skin reaction. If no reaction, VRN applies black pepper to hand or forearm using roller ball applicator.

a. 10 strokes distal to proximal on hand area or 12 strokes distal to proximal on forearm site.

b. Maximum dose of application is 3 ml.

c. VRN set timer to monitor exact time of application.

d. Observe 10 minutes following application.

6. VRN observes site and rates vein visibility and palpability.

7. VRN continues IVC access using hospital policy and practice for IVC insertion.

8. VRN documents post application scores.

9. VRN returns consent and data collection to Vascular Resource department for collection in locked cabinet.

10. Primary investigator reviews collected consents and data.

The control group followed the same procedure minus the patch test. Instead of black pepper, this group received standard nursing practice (heat and/or vigorous tactile stimulation).

Results

The results show that an improvement in vein score (1 or 2) occurred in both groups (Table 2). The overall change for the control group was 50/60 subjects (83%) while the overall change for the black pepper group was 54/60 subjects (90%). Most improvement (84 of 120 participants) was in the score 0 to 1 across both groups. However, 15 out of 60 participants (25%) in the black pepper group had full vein visibility and palpability after the intervention, but only 5 out of 60 (<10%) of participants in the control group achieved this. More importantly clinically, 6 out of 60 (10%) veins in the black pepper group remained nonvisible and nonpalpable, but 10 out of 60 (16%) participants in the control group had veins that remained nonvisible and nonpalpable. The six patients in the black pepper group who had nonvisible and nonpalpable veins after black pepper, then received standard nursing practice. However, the veins still remained nonvisible and nonpalpable despite three failed IVC attempts for four patients and two additional IVC attempts for the other two patients.

Table 2.

Results—Vein Visibility and/or Palpability After Intervention

	Vein still not visible or palpable	Vein now visible or palpable	Vein both visible and palpable	Total
Control group	10	45	5	60
Black pepper	6	39	15	60
Total	16	84	20	120

Using the Pearson chi-square test (Table 3), the results show black pepper made a significant difference to vein visibility and palpation (p=0.040). Finally, the number of IVC attempts in the black pepper group decreased from 116 to 67, but the number of IVC attempts in the control group only decreased from 87 to 67.

Table 3.

Pearson Chi-Square

	Value	df	Asymptomatic Significence (two-sided)
Pearson χ²	6.429	2	0.040
Likelihood ratio	6.672	2	0.036
Linear-by-linear association	5.419	1	0.020

Patient withdrawal

Two participants withdrew from the study. One patient withdrew from the study because he or she did not like the smell of the black pepper. One patient did not proceed following the patch test. The nurse did not believe the skin redness was related to the black pepper application because the patient had all over psoriasis, but she did not want to risk irritation.

Data analysis

IBM SPSS version 18 was used for data analysis. Data collection continued for 3 months and occurred during all shifts. It was collected by the six VRNs. The collected data were de-identified and stored separately from the informed consent forms.

Variables

Sex and age of both groups were analyzed to ensure both groups were comparable.

Sex

The black pepper group included 17 men and 43 women and the control group included 18 men and 42 women. A chi-square test was not statistically significant for sex and demonstrated similarity between both groups (p=1.0); however, the majority of both groups was female (See Table 4).

Table 4.

Demographic Data

	Control	Black pepper
Male	18	17
Female	42	43
No. of patients	55	58
Mean age	65.47	67.47
Standard deviation	16.120	17.182
Standard error	2.174	2.256

Age

Levene's test for equality of variance for age showed similarity of age in each of the two subject groups (p=0.527). Age was not recorded for eight patients (See Table 4).

Number of IVC attempts before the intervention

The number of attempts by the bedside nurse before asking for the VRN (prior to either intervention) was recorded. The number of attempts by the VRN (after either intervention) was also recorded.

Discussion

The purpose of this study was to compare the topical application of 20% black pepper essential oil to standard nursing care on vein visualization and palpability prior to intravenous catheter insertion of patients with limited vein accessibility hospitalized in a community teaching hospital. The data provides statistical evidence that using black pepper improved vein visibility and palpability more than standard nursing care. A higher percentage of subjects achieved optimal scoring (vein score=2) and a majority overall had improved response to black pepper intervention (vein score of 1 or 2). As well as the improvement in vein visibility and palpability, the study showed a greater reduction in the number of attempts of vein access post-intervention in the black pepper group. This is particularly interesting because the black pepper group needed more IVC attempts pre-intervention than the control group, and they therefore could be deduced to have more inaccessible veins.

The limitations of the study are a lack of variables that also contribute to poor vein access such as clinical diagnosis, presence of dehydration, or expertise of clinician.

Conclusion

Topical application of black pepper may be a viable and effective way to enhance vein visibility and palpability prior to intravenous catheter insertion in patients who have limited vein accessibility. Black pepper essential oil may improve vein access and reduce the need for repeated IVC attempts, thereby reducing patient discomfort and improving patient care. More studies are needed to discover if aloe vera gel enhances the effect of black pepper or has a measurable effect of its own within 10 minutes.

Footnotes

Acknowledgments

The authors wish to thank the Vascular Resource Nurses, Abington Memorial Hospital, for their role as data collectors, and Dr. Mary Naglak, PhD, Research Coordinator, Abington Memorial Hospital for her support with data analysis. Grant was received from the Nursing Education Research Council for supplies.

Author Disclosure Statement

The authors state that no competing financial interests exist.

a

Story L. Does Black Pepper applied topically enhance vein access prior to ICV insertion? Unpublished study for RJ Buckle aromatherapy certification. 2005.

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